FORM NO. E~5 Utility Code Loan Account No. Loan Applicant Name: ELECTRONIC CLEARING SERVICE (DEBIT CLEARING) MANDATE FORM (Please fill the form in Block letters) ‘The Manager Copy to the User Company Bank Name: Name : AXIS BANK LIMITED Branch Namo: Adds Address ATS, 10” Floor, C Wing, Solaris, Opp L& T Gate No. 6, SV Road, Powiai, Mumbai 72 Telephone No: —______________________-_ | aiesnone No : 022-40754110 I nereby authorize you to debit my account for making payment to ‘Axis Bank Limited’ through ECS (Debit) clearing as per the details, siven as under: ‘A.Name of the Account Holder (As per Bank's records) 'B. Account Number (Operative ale No) . Account Type ver Ci savings Wc Ci currentare cash credit C1 others: D.MICR -9 digit MICR Code umber of bank & branch . Ledger No/ Ledger Folio No. Date of etfect IName of the Schem Periodicity (PRODUCT) Amount of Number of cycle Date From To (MBimvtyietc) | Installment upto Installments | hereby declare that the Bank Account particulars given above are correct and complete. Ifthe transaction is delayed or not effected at al for reasons of incomplete or incorrect information, ! would not hold the user institution responsible. | have read the option Invitation letter and agree to discharge the responsiblity expected of me as a participant under the scheme. Date: - Signature of Account Holder (s) (Please affix a rubber stamp in case of companies, proprietorships, partnerships etc) (For office use only) Certified that the Bank Account particulars furnished above are correct as per our records & we have updated our records, (GankStamp) (Signature of authorized bank official) Date: Note: - 1. Mandate to be obtained in 3 Copies, Original for Bank, One for User Co and other for Customer 2, Please attach a blank cancelled cheque issued by your bank for verifying the accuracy of the MICR Code, ‘Transaction Code, A/C No and Signature.